Browsing by Author "Beneciuk, Jason M"
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Item Open Access Adding Physical Impairment to Risk Stratification Improved Outcome Prediction in Low Back Pain.(Physical therapy, 2020-09-24) Beneciuk, Jason M; George, Steven ZOBJECTIVE:Identifying subgroups of low back pain (LBP) has the potential to improve prediction of clinical outcomes. Risk stratification is one such strategy that identifies similar characteristics indicative of a common clinical outcome trajectory. The purpose of this study was to determine if an empirically derived subgrouping approach based on physical impairment measures improves information provided from the STarT Back Tool (SBT). METHODS:At baseline in this secondary analysis of a cohort study, patients (N = 144) receiving physical therapy for LBP completed the SBT and tests (active lumbar flexion, extension, lateral bending, and passive straight-leg-raise) from a validated physical impairment index. Clinical outcomes were assessed at 4 weeks and included the Numerical Pain Rating Scale (NPRS) and Oswestry Disability Index (ODI). Exploratory hierarchical agglomerative cluster analysis identified empirically derived subgroups based on physical impairment measures. Independent samples t testing and chi-square analysis assessed baseline subgroup differences in demographic and clinical measures. Spearman rho correlation coefficient was used to assess baseline SBT risk and impairment subgroup relationships, and a 3-way mixed-model ANOVA was used to assessed SBT risk and impairment subgroup relationships with clinical outcomes at 4 weeks. RESULTS:Two physical impairment-based subgroups emerged from cluster analysis: (1) Low-Risk Impairment (n = 119, 81.5%), characterized by greater lumbar mobility and (2) High-Risk Impairment (n = 25, 17.1%), characterized by less lumbar mobility. A weak, positive relationship was observed between baseline SBT risk and impairment subgroups (rs = .170). An impairment-by-SBT risk-by-time interaction effect was observed for ODI scores but not for NPRS scores at 4 weeks. CONCLUSIONS:Physical impairment subgroups were not redundant with SBT risk categories and could improve prediction of 4-week LBP disability outcomes. Physical impairment subgroups did not improve the prediction of 4-week pain intensity scores. IMPACT:Subgroups based on physical impairment and psychosocial risk could lead to better prediction of LBP disability outcomes and eventually allow for treatment options tailored to physical and psychosocial risk.Item Open Access Framework for improving outcome prediction for acute to chronic low back pain transitions.(Pain reports, 2020-03-04) George, Steven Z; Lentz, Trevor A; Beneciuk, Jason M; Bhavsar, Nrupen A; Mundt, Jennifer M; Boissoneault, JeffClinical practice guidelines and the Federal Pain Research Strategy (United States) have recently highlighted research priorities to lessen the public health impact of low back pain (LBP). It may be necessary to improve existing predictive approaches to meet these research priorities for the transition from acute to chronic LBP. In this article, we first present a mapping review of previous studies investigating this transition and, from the characterization of the mapping review, present a predictive framework that accounts for limitations in the identified studies. Potential advantages of implementing this predictive framework are further considered. These advantages include (1) leveraging routinely collected health care data to improve prediction of the development of chronic LBP and (2) facilitating use of advanced analytical approaches that may improve prediction accuracy. Furthermore, successful implementation of this predictive framework in the electronic health record would allow for widespread testing of accuracy resulting in validated clinical decision aids for predicting chronic LBP development.Item Open Access Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021.(The Journal of orthopaedic and sports physical therapy, 2021-11) George, Steven Z; Fritz, Julie M; Silfies, Sheri P; Schneider, Michael J; Beneciuk, Jason M; Lentz, Trevor A; Gilliam, John R; Hendren, Stephanie; Norman, Katherine SLow back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. The overall objective of this update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. It also focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments. J Orthop Sports Phys Ther 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304.Item Open Access Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care.(JAMA network open, 2021-02) Stevans, Joel M; Delitto, Anthony; Khoja, Samannaaz S; Patterson, Charity G; Smith, Clair N; Schneider, Michael J; Freburger, Janet K; Greco, Carol M; Freel, Jennifer A; Sowa, Gwendolyn A; Wasan, Ajay D; Brennan, Gerard P; Hunter, Stephen J; Minick, Kate I; Wegener, Stephen T; Ephraim, Patti L; Friedman, Michael; Beneciuk, Jason M; George, Steven Z; Saper, Robert BImportance
Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP.Objective
To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care.Design, setting, and participants
This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020.Exposures
SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral).Main outcomes and measures
Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records.Results
Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001).Conclusions and relevance
In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.Item Open Access Stratified care to prevent chronic low back pain in high-risk patients: The TARGET trial. A multi-site pragmatic cluster randomized trial.(EClinicalMedicine, 2021-04) Delitto, Anthony; Patterson, Charity G; Stevans, Joel M; Freburger, Janet K; Khoja, Samannaaz S; Schneider, Michael J; Greco, Carol M; Freel, Jennifer A; Sowa, Gwendolyn A; Wasan, Ajay D; Brennan, Gerard P; Hunter, Stephen J; Minick, Kate I; Wegener, Stephen T; Ephraim, Patti L; Beneciuk, Jason M; George, Steven Z; Saper, Robert BBackground
Many patients with acute low back pain (LBP) first seek care from primary care physicians. Evidence is lacking for interventions to prevent transition to chronic LBP in this setting. We aimed to test if implementation of a risk-stratified approach to care would result in lower rates of chronic LBP and improved self-reported disability.Methods
We conducted a pragmatic, cluster randomized trial using 77 primary care clinics in four health care systems across the United States. Practices were randomly assigned to a stratified approach to care (intervention) or usual care (control). Using the STarTBack screening tool, adults with acute LBP were screened low, medium, and high-risk. Patients screened as high-risk were eligible. The intervention included electronic best practice alerts triggering referrals for psychologically informed physical therapy (PIPT). PIPT education was targeted to community clinics geographically close to intervention primary care clinics. Primary outcomes were transition to chronic LBP and self-reported disability at six months. Trial Registry: ClinicalTrials.gov NCT02647658.Findings
Between May 2016 and June 2018, 1207 patients from 38 intervention and 1093 from 37 control practices were followed. In the intervention arm, around 50% of patients were referred for physical therapy (36% for PIPT) compared to 30% in the control. At 6 months, 47% of patients reported transition to chronic LBP in the intervention arm (38 practices, n = 658) versus 51% of patients in the control arm (35 practices, n = 635; OR=0.83 95% CI 0.64, 1.09; p = 0.18). No differences in disability were detected (difference -2·1, 95% CI -4.9-0.6; p = 0.12). Opioids and imaging were prescribed in 22%-25% and 23%-26% of initial visits, for intervention and control, respectively. Twelve-month LBP utilization was similar in the two groups.Interpretation
There were no differences detected in transition to chronic LBP among patients presenting with acute LBP using a stratified approach to care. Opioid and imaging prescribing rates were non-concordant with clinical guidelines.Funding
Patient-Centered Outcomes Research Institute (PCORI) contract # PCS-1402-10867.